How design can support mental health through crisis stabilization centers
March 30, 2023
Get to know the evolving space type filling a gap in America¡¯s mental health care
There¡¯s an ongoing mental health care crisis in America. In any given year, about one in four Americans, almost 60 million people, experiences a mental health issue. But the current system often sends a person in crisis to an overloaded emergency department. Or worse, it subjects them to an encounter with law enforcement during their most vulnerable time.
The mental health care crisis has been intensified by the COVID-19 pandemic, which disrupted social interaction in our day-to-day routine and stoked loneliness and anxiety. Factors like economic insecurity, health inequities, and addictions are further compounding mental health issues. This is especially true among youth and underrepresented communities.
Due to these and other stressors, we¡¯re seeing a spike in the volume of those in mental health crisis arriving at hospital emergency departments (ED). Roughly one in eight ED visits now stem from mental illness or substance use disorders. About half of all children who come to an ED with a mental health issue end up boarding in the ED.?
Crisis stabilization center courtyard for a confidential client.
An ED is meant for the most critical of medical emergencies. They are expensive to staff. Recent data suggests that only 10 percent of mental health high-cost patients had a hospitalization that wasn¡¯t related to mental health needs. The excessive wait times at EDs are likely to worsen the condition of those in crisis. Stand-alone psychiatric EDs may work for a hospital campus, but not every community has such extensive health infrastructure.
We¡¯re seeing the call for more mental health services and resources throughout our communities. Crisis stabilization centers have a key role to play in addressing this rise in mental health crises at the point of need.
What are crisis stabilization centers?
First responders can divert those having a critical mental health episode to a crisis stabilization center rather than to an ED or law enforcement setting. Centers provide a person in crisis with immediate access to care through a safe, deinstitutionalized, and therapeutic setting. Here, specially trained providers can set the course for an individual¡¯s recovery.
An example of a crisis stabilization center living room for a confidential client.
Crisis stabilization centers are for those who are medically stable but having a psychiatric episode¡ªperhaps due to addiction, a chemical or pharmacological imbalance, or psychological issue. They need to see the right staff, which includes psychiatric nurses that have crisis training, social workers, therapists, and psychiatrists. Staff can assess them quickly and move them into a safe environment for observation. After they can move to an inpatient or transitional outpatient setting.
The centers can be within or next to an existing hospital complex, connected to the hospital ED, or they can be freestanding facilities.
Making the crisis stabilization model work
The US is finally meeting the urgent need for crisis stabilization with funding and infrastructure. On July 16, 2022, the 988 Crisis Hotline went live. It created a nationwide network of call centers and mental health providers to respond to those in crisis more comprehensively. This hotline serves as a pipeline to crisis stabilization. Canada is considering a similar approach in the future.
Local governments are also developing affordable ways to supply more mental health services. The Alameda model has proven that high-functioning crisis response centers can increase access to care, decrease wait times, and eliminate ED boarding. This results in fewer inpatient admissions and reduces overall costs.?
Crisis stabilization centers are for those who are medically stable but having a psychiatric episode.
Federal funding for treatment programs and medical research has increased over the years. The government has budgeted billions for the Substance Abuse and Mental Health Services Administration, allowing greater investment in behavioral health facilities. And some states are investing in crisis stabilization within a new focus on citizens¡¯ mental health.
State and local healthcare systems are also partnering with private developer-driven entities to create these models of care, build the facilities, and function as specialized operators. Funding for mental health is getting bipartisan support in many states. These facilities can be an extension of an existing state or county facility, newly built, or retrofitted on an existing campus. In this way, every community can address the mental health crises specific to their needs.
Crisis stabilization centers utilize a variety of models of care and planning concepts. Generally, there are four key aspects.
The Nanaimo Regional General Hospital Emergency Department and Psychiatric Emergency Services in Nanaimo, British Columbia.
1. Intake
When a first responder determines that someone in crisis is medically stable, they will take that person to a crisis stabilization center for warm handoff (transfer of care from one health team member to another, sometimes in the presence of family) to the facility staff. The first responder or crisis mobilization team will share what condition and context they found the individual in, the issues they have observed, and ensure a proper transfer of custody for the patient.
The care team at the center can admit a new patient, typically through an interlocking entryway, and assess them immediately¡ªin contrast to the often-lengthy wait times for a psychiatric consult and evaluation at an ED. Delay of treatment can result in trauma, so speed of assessment and immediate access to care is key.
2. Observation
An individual will spend up to 23 hours in an observation area, a space where they feel safe, so the care team can get more information and understand the nature of their crisis. Is it a medication imbalance? An addiction issue? Is there a psychological issue that takes time to present? Or does the individual just need a safe space to gradually de-escalate?
The?EmPATH model concept focuses on ¡°treating patients in a calming, living room setting¡± with ¡°artwork, natural light, and sensory rooms.¡± We believe this model is well suited for crisis stabilization inpatient settings.
The Centre for Addiction and Mental Health Crisis & Critical Care Building in Toronto, Ontario.
3. Subacute inpatient units
The subacute setting is for patients who are medically stable but need additional care or observation. The care team can assess the patient over a longer period while building a recovery or care plan.
These subacute environments are a less expensive alternative to an inpatient psychiatric unit in a hospital. Their humanizing and deinstitutionalized environment can lower a person¡¯s stress. They are staffed with specially trained psychiatric nurses, social workers, and providers. With 16 beds or less, they are more intimate than inpatient facilities. Their homelike and hospitality-oriented dormitory-style rooms give some privacy and reinforce dignity.
4. Outpatient care
Those who are in crisis but don't need continuing observation and patient care can use outpatient spaces for transitional care and various forms of therapy. Transitional care (sometimes labeled a ¡°day hospital program¡± or ¡°intensive outpatient program¡±) can consist of intensive, often daylong adjunctive therapies, consults, counseling, and group therapy, depending on the patient¡¯s care plan.
Designing for dignity in healing spaces
Crisis stabilization centers are evolving. We will be sure to let the principles of design for mental health¡ªevidence-based approaches that value dignity, empathy, and patient experience¡ªguide us in our designs for these important and much-needed healing spaces.